Healthcare Provider Details

I. General information

NPI: 1245236884
Provider Name (Legal Business Name): NIDAL SHAWAHIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DR STE. 360
BELLEVILLE IL
62226-5368
US

IV. Provider business mailing address

4600 MEMORIAL DR STE. 360
BELLEVILLE IL
62226-5368
US

V. Phone/Fax

Practice location:
  • Phone: 618-222-7280
  • Fax: 618-222-7281
Mailing address:
  • Phone: 618-222-7280
  • Fax: 618-222-7281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036087648
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: